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Enuresis (bedwetting) and Attention Deficit Hyperactivity Disorder (AD/HD or ADD) are both common conditions that can affect children and adolescents. Although there is no evidence that either one causes the other, children with AD/HD appear to have a higher incidence of enuresis. The child with AD/HD may feel different and unaccepted. Enuresis might exacerbate these feelings. There are several medically accepted treatments for enuresis. Some of them require impulse control and cooperation. Might this be more difficult for individuals with AD/HD? Individuals with AD/HD may be taking medications for the condition. How might these medications affect their enuresis?
We all wet the bed at some point in our lives. When a baby’s bladder fills to a certain point, the bladder muscles contract, and the baby urinates. Over time, the young child’s nervous system matures. The feedback circuits between the brain and the bladder enable the child to realize when his or her bladder is full. The child becomes physically able to delay urination until he or she decides that it is the appropriate time and place to void. Different children develop the neurological and emotional capacity to control their bladders at different ages. In many cases, children learn to control their bladders during the day before they master nighttime dryness. Occasional episodes of daytime or nighttime bladder accidents after five may be a normal part of growing up. . However, if a child continues to have regular trouble controlling his bladder after age five, he meets the criteria for enuresis. Bedwetting (nocturnal enuresis) usually does not occur while the child is dreaming. It is more likely to happen during the deeper phases of sleep.
How common is bedwetting? The reported incidence varies depending on the study. Children do not like to admit to this problem. Thus the actual incidence may actually be higher than some estimates. At age five the incidence is between 5-20%. It is much more frequent in boys than in girls. The incidence drops significantly with age. A general rule of thumb is that about 15% of children achieve nighttime dryness each year after age 5. At age 5, enuresis affects 7% of boys and 3% of girls. By age 10, it affects 3% of boys and 2% of girls. About 1% of adolescents still experience enuresis. That 1% may not sound like much, but it translates into a large number of adolescents and young adults with an embarrassing—sometimes-humiliating—problem. What causes enuresis? We do not know an exact cause of nighttime enuresis.
Treatment of enuresis: If the enuresis is related to a specific physical or emotional issue, the causative factor must be addressed. For the majority of children, there is not specific cause. It is often best to counsel the families of young children to wait and see whether the child becomes dry within the next year or two. Parents should not be harsh or judgmental. Sometimes it is the emotional reaction of the parent that causes the psychological hurt, more than the bedwetting itself. The child is often the best one to determine whether the bedwetting is a problem. Does the bedwetting bother him? Does it interfere with sleepovers or camping trips? The incidence of enuresis declines by about 15% per year after age five. Bladder capacity increases, an overactive bladder may normalize, the child learns to recognize the signal that it is time to void, and stressful events may fade.
However, some children do require extra intervention for their bedwetting. Initial interventions may include:
Like enuresis, AD/HD is also a common childhood condition. . Individuals with inattentive ADHD have difficulty paying attention and staying organized. Individuals with impulsive or combined ADHD have difficulty with attention and organization but also are overly active and impulsive ADHD affects 3-5% of school-aged children. Although most children with enuresis experience remission of their enuresis by age 18, a higher percentage of individuals with AD/HD continue to experience inattention and impulsivity well into adulthood. For years, clinicians have anecdotally noted an increased incidence of enuresis in children with AD/HD. Others have observed that their patients with enuresis have an increased incidence of AD/HD. Because both conditions are fairly common, it would be important to have more systematic studies that looked at the relationship between enuresis and AD/HD.
An article in the Southern Medical Journal published in 1997compared a fairly large group of 6-year-old children with AD/HD to a non-AD/HD control group selected from a pediatric clinic population. They found that the 6-year-olds with AD/HD had 2.7 times higher incidence of enuresis and a 4.5 times higher incidence of diurnal (daytime) enuresis as compared to a control group Other authors have cited higher rates of enuresis in children with ADHD. However, these studies did not have control groups or were not selected randomly.
Sometimes enuresis may be more upsetting for a child with AD/HD. A non-AD/HD child, who is successful in most spheres, may be able to accept his bedwetting more easily. Later, such a child may find it easier to cooperate with behavioral interventions. However the child with ADHD already feels different from his peers. His disorganization and impulsivity may lead to peer rejection and shame. Such a child may cover his shame with a false appearance of bravado. And although he may be more ashamed of his bedwetting, his inattention and disorganization may make it more difficult for him to cooperate with some behavioral treatments. Individuals with AD/HD are more likely to have sleep problems. Some of them sleep deeply and have difficulty waking up to go to the bathroom when their bladder is full.
Treating the child with both AD/HD and enuresis: This child should have a complete physical exam. It is important to always ask an individual with AD/HD about current and past bedwetting problems. Don’t neglect to ask adolescents about this too. They will rarely volunteer this information on their own. Ask what they and their parents have tried in the past. Some children and teens with AD/HD are veterans of many types of therapy. They may already expect the treatment to fail. The behavioral techniques listed earlier in the article are still useful for these children and teens. Since these children have often experienced teasing and criticism, one should be especially careful to avoid punitive behavioral techniques. One may have to modify behavioral interventions to accommodate the child’s shorter attention span. You may need to prioritize symptoms. If the child has a myriad of behavior difficulties, the family cannot address all of them at once. Which ones are the most important to the child and the parent? Some children and families opt to wait a while longer before starting behavioral or medical interventions. When the family decides that this is the time to treat the enuresis, they may have to back off with some of their other behavioral goals to avoid being overwhelmed. The child and family should be made aware that there are several ways to treat the enuresis. If one does not work, you are not a failure. You still have plan B, plan C, etc.
Medication for children with both AD/HD and enuresis. Some children with AD/HD may also have other psychiatric disorders and may be on several medications. A few of these medications might exacerbate the enuresis. It is important to consider all medications and all medical conditions before proceeding with treatment. DDAVP help the enuresis of some children and teens with AD/HD.. In other cases, one may want to consider one of the tricyclic antidepressants for the enuresis. This class of medication seems to work well with some of the “deep sleeper” kids.. You may be able to treat both the AD/HD and the enuresis with one medication. Several studies have shown that the tricyclics by themselves are an effective medical treatment for AD/HD in children and adults In some cases, one can combine stimulants and tricyclics. Such cases may require more frequent medical monitoring.
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